Therapeutic Approaches to Patients with Mucous Membrane Pemphigoid A. Shadi Kourosh, MD*, Kim B. Yancey, MD This article summarizes the treatment of mu- cous membrane pemphigoid (MMP), a treatment- resistant disease for which the goal of therapy is control of symptoms and preservation of function. The arsenal of therapeutics is roughly the same as that for bullous pemphigoid with additional em- phasis on site-directed therapy as the guiding principle of management. Vigilant review of symptoms, examination of mucous membranes and skin to determine all sites of involvement, and prompt referral to subspecial- ists (ie, ophthalmologists, otolaryngologists and so forth) to assist in evaluation and management of affected sites, can make the difference between independent functioning and disability for patients with MMP, especially those with ocular and laryn- geal involvement. The involvement of certain mucosal sites (ie, ocular, genital, nasopharyngeal, esophageal, and laryngeal mucosal sites) is considered high risk and warrants more aggres- sive intervention. As in the treatment of any auto- immune disease, effective treatment must be reconciled with efforts to minimize the adverse effects of exposure to systemic glucocorticoste- roids and/or other immunosuppressives. APPROACH TO PATIENTS WITH LOW-RISK DISEASE Low-risk disease (eg, involvement of only the oral mucosa and/or skin sites with less tendency and/ or clinical significance of scarring) is managed first with topical corticosteroids of moderate to high potency. Available forms include mouthwash (dexamethasone swish-and-spit) and topical corti- costeroid gels or ointments. To facilitate adsorption, gels and ointments can be used under occlusion with oral, insertable, vinyl, prosthetic devices (ie, dental trays). 1,2 Avoidance of toothpastes contain- ing sodium lauryl sulfate and mouthwashes con- taining alcohol may further aid in the control of symptoms. Treatment may be escalated with in- tralesional glucocorticosteroid injections and systemic therapies, such as dapsone, low morning doses of prednisone, or the prednisone in combi- nation with azathioprine or mycophenolate mofetil (Table 1). 3–6 APPROACH TO PATIENTS WITH HIGH-RISK DISEASE For patients with high-risk disease (eg, with involve- ment of ocular, genital, nasopharyngeal, esophageal, and/or laryngeal mucosal sites) systemic glucocor- ticosteroids (ie, prednisone at doses of 1 mg/kg/d) in combination with glucocorticosteroid-sparing agents have been the mainstay of treatment (Table 1). Although the lack of large-scale, random- ized, controlled studies of therapeutic regimens has been limiting in guiding evidence-based prac- tices for clinicians in this arena, the First Interna- tional Consensus Conference on MMP supports initial treatment with prednisone (1 mg/kg/d) in combination with an agent that disrupts the purine Disclosures: None. Conflicts of Interest: None. Department of Dermatology, University of Texas Southwestern Medical Center in Dallas, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA * Corresponding author. E-mail address: askderm@gmail.com KEYWORDS  Immunosuppressives  Mucosal sites  Interdisciplinary  Glucocorticosteroids Dermatol Clin 29 (2011) 637–641 doi:10.1016/j.det.2011.06.022 0733-8635/11/$ – see front matter Ó 2011 Elsevier Inc. All rights reserved. derm.theclinics.com